Parkinson's disease (PD) is a neurodegenerative disorder that progresses over time, marked by bradykinesia (slowed movements), tremor (rhythmic shaking), and stiffness. As the condition worsens, patients may experience postural instability, finding it difficult to balance and maintain upright posture. Worldwide, Parkinson's disease affects around 3% people over 65 years of age. PD's incidence and prevalence varies widely across geographic regions and shows spatial clustering, including higher rates in North America and Europe than in Asia and Africa.

Parkinson's disease (PD) involves the gradual degeneration of dopamine producing neurons in a brain region called the substantia nigra and other related cell groups in the brainstem. This is accompanied by the accumulation of misfolded proteins such as alpha-synuclein. Alpha-synuclein is normally found in the presynaptic terminals of neurons. If alpha-synuclein is mis-folded and not cleared from cells by cellular degradation systems, it can build up to form clumps of proteins called Lewy bodies and Lewy neurites. Accumulation stimulates the release of pro-inflammatory molecules by the microglia, a protective response that can cause inflammation and neuronal damage if it becomes chronic. Neuroinflammation causes the blood-brain barrier (BBB) to become more permeable, allowing dangerous substances and inflammatory cells to enter the brain and interfere with metabolic functions. Dysfunction in mitochondria, which are central to cellular energy production, increases oxidative stress and cell death. Protein aggregation, inflammation and metabolic dysregulation in lysosomal, endosomal, and mitochondrial systems are interconnected mechanisms which create a cycle of inflammation, cellular stress and damage in Parkinson's disease.

PD has no single cause: rather, genetic and environmental factors interact and affect critical cellular processes in a complex interplay. Genetically, from 15 to 25% of people with PD report familial connections who have PD, and 10–20% report a first-degree relative with PD. PD risk is increased by variations in specific genes, many of which have been linked to specific neural mechanisms. Familial parkinsonism involving an autosomal dominant or recessive pattern commonly results in early-onset PD. Research has indicated that the risk of Parkinson's disease (PD) is increased by mutations in the genes encoding leucine-rich repeat kinase 2 (LRRK2), Parkinson's disease-associated deglycase (PARK7), PRKN, PINK1, and SNCA (alpha-synuclein).

The remaining 80-90% of PD cases are classified as sporadic or idiopathic, meaning no clear single cause or mechanism has been determined for them. The cumulative effects of many different environmental exposures over a lifetime interact with underlying genetic factors to influence PD development and progression. Both risk factors and protective factors are known to relate to Parkinson's disease. Exposures to pesticides, metals, solvents, other toxicants and air pollution are increasingly seen as major risk factors in PD development. The brain is particularly vulnerable to chemicals that are able to cross the blood-brain barrier. Body-first and brain-first models of Parkinson's disease propose that there are two distinct avenues through which environmental toxicants can enter the nervous system: (1) ingested into the gut and affecting the enteric nervous system (body-first), or (2) inhaled through the nose and affecting the olfactory bulb (brain-first). The World Health Organization (WHO) recommends reducing exposure to environmental factors associated with PD, including pesticides, trichloroethylene (TCE), and air pollution. Traumatic brain injury and Type 2 diabetes are additional risk factors. Exercise, coffee consumption, and diets rich in fruits, vegetables, whole grains, and fish are protective factors associated with lower risk of PD.

Genetic factors

Traditionally, Parkinson's disease has been considered a non-genetic disorder. However, between 15 and 25% of people with PD report familial connections who have PD, and from 10 to 20% have a first-degree relative with PD. No single-gene mutation in PD causes PD, but multiple genetic factors can increase susceptibility and the risk of developing either familial or sporadic PD. More penetrant PD mutations with a higher risk of developing the disease, tend to be rare but are often associated with familial PD (e.g. rare SNCA variants). A second group of variants (including GBA and LRRK2 variants) are uncommon and carry an intermediate level of risk in a significant minority of PD cases. A third group of genetic variants occur often but carry low risk.

Unequivocal links to PD pathogenesis have been found for mutations in at least six genes: LRRK2, SNCA, and VPS35 (dominant forms) and PRKN/Parkin, PINK1, and PARK7/DJ1 (recessive forms). The most extensively studied PD-related genes are LRRK2 and SNCA.

At least 16 genes display "causal" variants associated with genetic predisposition for PD, through higher familial inheritance of PD or development of early-onset PD symptoms. An additional 44 novel risk loci have been associated with sporadic PD.

Both autosomal dominant and autosomal recessive gene mutations have been implicated in the development of PD. Autosomal dominant genes include SNCA (PARK1, PARK4, NCAP) and VPS35 (PARK17, MEM3), which are rare but highly penetrant, and CHCHD2. LRRK2 (PARK8, DARDARIN) and GBA (GBA1) are pathogenic but have variable penetrance. Dominant genes associated with PD but now believed unlikely to be pathogenic include HTRA2, UCHL1 (PARK5), GIGYF2 (PARK11), and EIF4G1. Autosomal recessive genes include PRKN (PARK2, PARKIN), PINK1 (PARK6), PARK7 (DJ-1), ATP13A2 (PARK9), PLA2G6 (PARK14, IPLA2), FBXO7 (PARK15, FBX7), DNAJC6 (PARK19, DJC6), SYNJ1 (PARK20), and VPS13C (PARK23).

Most common risk genes (like GBA) affect both sexes equally. The overall genetic risk for PD appears to be similar for males and females. However, there are sex- and gender-related differences between men and women in PD clinical features, disease development and response to treatment. Men are consistently found to have a higher occurrence of Parkinson's disease, with an estimated prevalence rate 1.5 times greater among males than females across all ages. These differences appear to reflect complex interactions among hormones, gene regulation, and other biological, environmental and sociocultural factors. Some sex-linked factors may differently affect brain activity and dopamine pathways. In adult males, the SRY gene (Sex-determining Region on the Y chromosome) is involved in regulation of dopamine, and SRY overactivity may increase PD risk. In women, hormones such as estrogen have been suggested to have a protective effect against PD, but little research has been done.

Autosomal dominant genes SNCA gene The SNCA gene encodes alpha-synuclein. The role of the SNCA gene is significant in PD because the alpha-synuclein protein is the main component of Lewy bodies, which appear as a primary biomarker in the disease. Missense mutations of the gene (in which a single nucleotide is changed), and duplications and triplications of the locus containing it, have been found in different groups with familial PD. Level of alpha-synuclein expression correlates with disease onset and progression, with SNCA gene triplication advancing earlier and faster than duplication. Missense mutations in SNCA are rare. On the other hand, multiplications of the SNCA locus account for around 2% of familial cases. Multiplications have been found in asymptomatic carriers, which indicate that penetrance is incomplete or age-dependent.

LRRK2 gene The LRRK2 gene (PARK8) encodes for the protein leucine-rich repeat kinase 2 (LRRK2/dardarin). Mutations in the LRRK2 gene account for the majority of autosomal-dominant Parkinson's disease cases. These mutations are the most common known cause of familial and sporadic PD, accounting for approximately 5% of individuals with a family history of the disease and 1% of apparently sporadic cases.

Many individuals carrying LRRK2 mutations do not develop PD, and estimates of the likelihood of developing PD vary widely with different mutations. LRRK2 is reported to have over 100 genetic coding variants. Of these, only six (G2019S, I2020T, R1441C/G/H, and Y1699C) have been reliably shown to be pathogenic, based on PD family groupings, and three more (I1372V, R1628P, and G2385R) are suspected to be PD genetic risk factors. The occurrence of LRRK2 variants differs based on population and ethnicity. G2019S is found in most countries, with higher frequency in Ashkenazi Jewish and Berber populations. R1628P and G2385R appear in Asian populations.

LRRK2 is involved in the protein uptake, movement and clearance activities of the endolysosomal system, which degrades and removes unwanted proteins, preventing toxic build-up. LRRK2 and alpha-synuclein interact. Some LRRK2 mutations have been linked to dysfunctional protein degradation and clearance. For example, G2019S mutations appear to reduce the ability to clear alpha-synuclein, the protein which forms Lewy bodies. G2019S may also be linked to tau pathology.

VPS35 VPS35 (PARK17, MEM3) is involved in cellular transport mechanisms such as endosomal trafficking, the sorting and recycling of proteins in the cell. Such recycling is essential to normal cell functioning. Normally VPS35 regulates the sorting and transport of proteins controlling mitochondrial fusion and fission. Absence or mutation of VPS35 can cause mitochondrial fragmentation, the accumulation of damaged mitochondria within the cell, and impaired function. The VPS35 D620N mutant further interferes with the activity of PINK1 and PRKN in recycling damaged mitochondria. VPS35 mutations are related to a number of diseases that involve disruptions of normal mitochondrial and retromer activity, including PD. VPS35-related PD is extremely rare.

GBA gene The GBA gene is associated with lysosome storage and autophagy. GBA encodes the enzyme glucocerebrosidase (GCase), necessary for breaking down glucosylceramide (GlcCer). Mutations in GBA can cause modifications in GCase protein structure, decreases in GCase activity and protein levels, and the accumulation of GlcCer in the cell. Approximately 5–15% of PD patients have mutations in the GBA gene. Mendelian genetics are not strictly observed in GBA mutations in PD. Both gain-of-function and loss-of-function GBA mutations are associated with increased risk of PD.

GBA is one of a number of pleiotropic genes which have multiple effects in the body, that have been linked to PD risk. Mutations in GBA1 can cause either complete loss‐of‐function and the lysosomal disorder Gaucher's disease, or partial loss‐of‐function with an increased risk for PD. Mutations in EPG5 are implicated in a range of dysfunctions, from severe (Vici syndrome), to moderate (atypical parkinsonism) and mild (typical PD). Microdeletions at 22q11.2 have been variously linked to PD, schizophrenia, and DiGeorge syndrome.

Autosomal recessive genes PINK1, PARK7, PRKN PINK1 (PARK6), PARK7 (DJ-1), and PRKN (PARK2, PARKIN) are all involved in mitochondrial activity. Mutations in these genes may cause mitochondrial dysfunction, an element of both idiopathic and familial PD.

In addition, the PRKN gene encodes E3 ubiquitin ligase, which is involved in degradation of damaged proteins by ubiquitin. Many different PRKN-related mutations occur, leading to loss of protein or to protein-related loss of function. PRKN is the most common cause of autosomal-recessive PD, accounting for nearly 50% of typical early-onset parkinsonism. PRKN mutations account for 77% of juvenile PD cases.

PINK1 encodes PTEN-induced putative kinase 1, and is the second-most common cause of autosomal-recessive PD.